Provider Demographics
NPI:1689990822
Name:CONNALLY, JADA RAE (LAT)
Entity Type:Individual
Prefix:MISS
First Name:JADA
Middle Name:RAE
Last Name:CONNALLY
Suffix:
Gender:F
Credentials:LAT
Other - Prefix:
Other - First Name:JADA
Other - Middle Name:
Other - Last Name:MCBRYDE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:5510 RIO GRANDE AVE
Mailing Address - Street 2:
Mailing Address - City:MIDLAND
Mailing Address - State:TX
Mailing Address - Zip Code:79707-9701
Mailing Address - Country:US
Mailing Address - Phone:318-564-0376
Mailing Address - Fax:
Practice Address - Street 1:5615 DEAUVILLE STE 220
Practice Address - Street 2:
Practice Address - City:MIDLAND
Practice Address - State:TX
Practice Address - Zip Code:79706-2707
Practice Address - Country:US
Practice Address - Phone:432-221-4004
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-04-13
Last Update Date:2022-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXAT43252255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer